| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
632 |
624 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
517 |
511 |
$2K |
| D0330 |
Panoramic radiographic image |
186 |
186 |
$2K |
| D1120 |
Prophylaxis - child |
539 |
534 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
141 |
92 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
125 |
125 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
241 |
120 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
262 |
126 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$0.00 |
| D1351 |
Sealant - per tooth |
157 |
42 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
143 |
143 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
24 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
489 |
176 |
$0.00 |